Kim Bo, Sullivan Jennifer L, Brown Madisen E, Connolly Samantha L, Spitzer Elizabeth G, Bailey Hannah M, Sippel Lauren M, Weaver Kendra, Miller Christopher J
Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, 150 South Huntington Avenue, Boston, MA, 02130, USA.
Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA.
Implement Sci. 2024 Feb 19;19(1):16. doi: 10.1186/s13012-024-01342-2.
Sustaining evidence-based practices (EBPs) is crucial to ensuring care quality and addressing health disparities. Approaches to identifying factors related to sustainability are critically needed. One such approach is Matrixed Multiple Case Study (MMCS), which identifies factors and their combinations that influence implementation. We applied MMCS to identify factors related to the sustainability of the evidence-based Collaborative Chronic Care Model (CCM) at nine Department of Veterans Affairs (VA) outpatient mental health clinics, 3-4 years after implementation support had concluded.
We conducted a directed content analysis of 30 provider interviews, using 6 CCM elements and 4 Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) domains as codes. Based on CCM code summaries, we designated each site as high/medium/low sustainability. We used i-PARIHS code summaries to identify relevant factors for each site, the extent of their presence, and the type of influence they had on sustainability (enabling/neutral/hindering/unclear). We organized these data into a sortable matrix and assessed sustainability-related cross-site trends.
CCM sustainability status was distributed among the sites, with three sites each being high, medium, and low. Twenty-five factors were identified from the i-PARIHS code summaries, of which 3 exhibited strong trends by sustainability status (relevant i-PARIHS domain in square brackets): "Collaborativeness/Teamwork [Recipients]," "Staff/Leadership turnover [Recipients]," and "Having a consistent/strong internal facilitator [Facilitation]" during and after active implementation. At most high-sustainability sites only, (i) "Having a knowledgeable/helpful external facilitator [Facilitation]" was variably present and enabled sustainability when present, while (ii) "Clarity about what CCM comprises [Innovation]," "Interdisciplinary coordination [Recipients]," and "Adequate clinic space for CCM team members [Context]" were somewhat or less present with mixed influences on sustainability.
MMCS revealed that CCM sustainability in VA outpatient mental health clinics may be related most strongly to provider collaboration, knowledge retention during staff/leadership transitions, and availability of skilled internal facilitators. These findings have informed a subsequent CCM implementation trial that prospectively examines whether enhancing the above-mentioned factors within implementation facilitation improves sustainability. MMCS is a systematic approach to multi-site examination that can be used to investigate sustainability-related factors applicable to other EBPs and across multiple contexts.
维持循证实践（EBPs）对于确保医疗质量和解决健康差异至关重要。迫切需要确定与可持续性相关因素的方法。矩阵式多案例研究（MMCS）就是这样一种方法，它可以识别影响实施的因素及其组合。在实施支持结束3至4年后，我们应用MMCS来确定九家退伍军人事务部（VA）门诊心理健康诊所中与循证协作式慢性病护理模式（CCM）可持续性相关的因素。
我们对30名提供者访谈进行了定向内容分析，使用6个CCM要素和4个卫生服务研究实施综合促进行动（i-PARIHS）领域作为编码。根据CCM编码总结，我们将每个站点指定为高/中/低可持续性。我们使用i-PARIHS编码总结来确定每个站点的相关因素、其存在程度以及它们对可持续性的影响类型（促进/中性/阻碍/不明确）。我们将这些数据整理成一个可排序的矩阵，并评估与可持续性相关的跨站点趋势。
CCM的可持续性状况在各站点中分布不同，高、中、低可持续性的站点各有三个。从i-PARIHS编码总结中识别出25个因素，其中3个因素在可持续性状况方面呈现出强烈趋势（方括号内为相关的i-PARIHS领域）：在积极实施期间及之后，“协作性/团队合作[接受者]”、“员工/领导层更替[接受者]”以及“有一致/强大的内部促进者[促进]”。仅在大多数高可持续性站点中，（i）“有知识渊博/乐于助人的外部促进者[促进]”存在差异，存在时可促进可持续性，而（ii）“对CCM包含内容的清晰认识[创新]”、“跨学科协调[接受者]”以及“为CCM团队成员提供足够的诊所空间[背景]”在一定程度上或较少存在，对可持续性的影响各异。
MMCS表明，VA门诊心理健康诊所中CCM的可持续性可能与提供者协作、员工/领导层过渡期间的知识保留以及熟练内部促进者的可用性最为相关。这些发现为后续的CCM实施试验提供了参考，该试验前瞻性地研究在实施促进过程中增强上述因素是否能提高可持续性。MMCS是一种用于多站点检查的系统方法，可用于调查适用于其他循证实践和多种背景的与可持续性相关的因素。
